Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is one of the most respected forms of therapy currently in practice. It is used to help a host of mental health-related issues and disorders, including substance abuse. The history of CBT provides insight into how this form of therapy evolved and has maintained its commitment to being a pragmatic and effective approach. The following is a historical timeline of CBT, in broad strokes:

In the mid-1960s, what is today called Cognitive Behavioral Therapy was first developed, but it mainly had a cognitive focus. At that point in time, cognitive approaches and behavioral approaches were separated in the therapy field. CBT always had a practical focus and started out by addressing phobias. This is unique because unlike other therapy approaches, like psychoanalytic theory, CBT results could be quantified. An improvement in a client’s phobia either would or would not occur. In other words, CBT could have visible results, and this fact still holds true today.

In the 1970s, what is today called CBT was integrated into behavioral therapy. This was a leap within the therapy field. Dr. Aaron Beck played an instrumental role in expanding the use of CBT beyond phobias. Dr. Beck used CBT to treat clients with depression and found this approach to be exceptionally effective. In fact, research shows that CBT can be as effective as medication in the treatment of depression.

In the 1980s, CBT was applied to mood disorders and found to be effective.

At the end of the 1980s, therapist Jeff Young developed a form of CBT that he called schema therapy. He applied this method to personality disorders and found it to be effective.

In the 1990s and thereafter, CBT was widely accepted as a master approach to treating psychological disorders. Today, it is widely practiced and highly regarded.

Speaking broadly, therapy is about individuals finding an effective way to bring about changes in their lives. As Dr. Jason M. Satterfield, a clinical psychologist with the University of San Francisco Medical Center notes, the following are some of the main mechanisms of change within the field of therapy:

Psychotherapy (also called therapy).

Pharmacology (medications)

Neurosurgeries (e.g., for obsessive-compulsive disorder)

Self-help

Spirituality (sometimes referred to as third wave therapy)

There are numerous therapy approaches, some work within a niche and others have broader applications, such as Cognitive Behavioral Therapy. Therapy can be seen as an alternative to prescription medications (also called pharmacological therapy) or used in conjunction with them. Although different therapies can bring relief, it should be noted that research shows the type of therapy a person receives can impact the brain differently. For example, Dr. Satterfield explains that 21 studies of the brain found physical changes in the pattern of the brain after psychotherapy (some of these studies focused on CBT). In those participants who used medications rather than therapy, it appeared that different areas of the brain were affected. This finding suggests that in the future, as research advances, there may singular or combined therapies that improve a mental health disorder or a substance use disorder by targeting certain regions of the brain.

CBT Basics in Practice

As Dr. Satterfield explains in a lecture that is part of The Great Courses series, Cognitive Behavioral Therapy aims to improve a person’s philosophy of mind. CBT can train a person to have thoughts about thoughts and feelings about feelings. Stated another way, CBT can help a person to learn how to observe the inner landscape of the mind rather than repeatedly react to external stimuli. There are reasons for reactions. But, as CBT notes, these reactions can be interrupted, by thinking about them. But how?

Thoughts can be used to intervene on thoughts. In the area of drug cues, for example, a person may see drug paraphernalia and react by using drugs. However, if this person wants to stop using drugs and knows some principles of CBT, this person can learn that there’s a mental pause button between stimuli and reaction. The person could say, “I feel like doing drugs right now because I saw some paraphernalia. Do I really want to do drugs right now? If I do drugs right now, how will I feel after? Do I want to put myself in that position?” This type of self-inquiry can give a person the breathing room to make an informed decision vis-à-vis drugs or any stimuli. In other words, this type of thought investigation (where the thought, for example, is “I want to do drugs.”) can derail a reaction/automatic response (in this example, doing drugs).

Dr. Satterfield, in describing the basics of Cognitive Behavioral Therapy, explains that he uses a CBT triangle with his clients and as part of his training of future mental health professionals. The triangle is labeled thoughts at one point, behaviors at the second point, and emotions at the third point. Dr. Satterfield explains that this diagram makes clear how all three points are interconnected. If a person can intervene on a thought, then they can change a behavior and/or emotion. Part of the CBT philosophy of mind is understanding that no one is a prisoner of thoughts, and there are no set behaviors or emotions that have to be experienced.

For example, imagine a person is walking down the street and gets hit by a water balloon. This person does not have to react with anger and lash out, or feel an emotion such as worthlessness. If this person walking down the street has had CBT and is committed to optimizing their own peacefulness, they could do something therapists call participating.

When individuals participate in their thoughts, they think about how they are feeling about a particular situation rather than automatically reacting to it. Here is one hypothetical possibility in the water balloon scenario: The person could think, “Wow, what just happened? I’m soaked. Oh look, some kids are playing in the street; they didn’t mean it. Well, it’ll dry, good thing it’s sunny out!” In this scenario, the person takes a moment to understand what has happened and, with that information, does not become angry or feel a negative emotion. Yes, this person sounds very optimistic and quickly turns those proverbial lemons into lemonade, but why not? A main key is that the person’s peace of mind is not lost, at least not for more than a couple moments. Once we understand that we control our reactions and we live in our own minds, we also understand that it’s up to us to make our mental space as pleasant and comfortable as possible. CBT can help a person do just that.

Features of CBT

In Dr. Satterfield’s multipart lecture, he outlines the main features of Cognitive Behavioral Therapy. Again, CBT can be used to treat a host of mental health disorders, substance use disorders, co-occurring disorders, and many subclinical issues (e.g., to help a person improve confidence). The technique is similar across different client disorders and issues but adjusted to each client’s specific needs. The following is a list and brief explanation of features of CBT.

The process is collaborative and transparent: The CBT therapist is not an authoritarian figure. Rather, the therapist and client work together to collect information on the client’s problems and then develop a plan together to relieve those issues. The therapist and client work through the plan (talk about it, adjust it as necessary, etc.) during sessions and over the course of the CBT treatment. The goal of CBT is to teach clients how to be their own therapist, coach, advisor and support system.

Empirically based: As noted earlier, CBT has also sought to improve issues and problems the client works on in therapy. When the therapist and client collaborate, they will come up with a way to resolve an issue. The client, through homework and additional personal efforts, will try out that idea and see if it works. If it does not, the therapist and client will come back to the drawing board, come up with a new approach, and see if it works for the client.

Limited in time: There’s always an end point to CBT. Certain therapies, such as the psychoanalytic approach, can last for years or even a lifetime. Since CBT aspires to teach clients to be their own guides, it is focused on client empowerment, and it aims to last only as long as needed.

Focused on building skills: CBT is about practice. The therapist will teach the client techniques and help the client to embody them, but it’s a process of client empowerment that does not promote reliance on the therapist. Once the tools of CBT are in place, clients have the power to be their own best counselor.

Focused on symptoms: The therapist will assess and reassess the client’s symptoms over the course of treatment. As symptoms are manifestations of an underlying issue, if CBT is working on the issue, the symptoms should improve. For this reason, the evolution of symptoms (i.e., if they improve, stay the same, or go into remission) acts as a sort of checklist for the client and therapist. This sort of feedback is instrumental to the process.

Focused on a person’s current reality/the present moment: In CBT sessions, the therapist helps the client with current feelings, behaviors, thoughts, and circumstances. The technique to do this is considered top down, which means that the therapist starts broadly and then works into deeper psychological complexes. The therapist moves discussions over the course of treatment from how a client feels, to what’s going on in the client’s everyday life, to working with the client to look at facets of the client’s personality, and then to working with the client at the client’s relationship dynamics. It is crucial, for these reasons, that the therapist and client trust one another and have a good working relationship. Again, it’s a professional setup but a collaborative process.

As the features of CBT suggest, this approach can be considered, at least in part, to be like a course in self-help. One of the greatest assets of CBT is its insight that people, if empowered with effective skills, can help themselves to maintain a balanced mind and lead a fulfilling life. As noted, the transparency of CBT supports this goal. The therapist is not like a magician; there’s no desire to hide the process. Learning the process is itself part of the therapy.

CBT in Substance Abuse Treatment

Dr. Aaron Beck, as noted earlier, is one of the main founding practitioners of CBT. During a workshop at the Beck Institute for Cognitive Behavioral Therapy, when asked about the usefulness of CBT in substance abuse treatment, Dr. Beck only confirmed what is well established: CBT has been shown to be effective in the treatment of alcohol and other drug addictions. As Dr. Beck explained during the workshop, CBT can help a person to interrupt drug use cues. Dr. Beck discussed how important it is for a CBT therapist to work with a client to build skills that can be used in real-world scenarios, such as if a drug cue arises.
Dr. Beck spoke about a specific technique while addressing the workshop; it is not known whether therapists regularly use this technique, but Dr. Beck appears to find it entirely acceptable and effective. Dr. Beck explained that a CBT therapist could bring drug paraphernalia to a session and a simulated drug (e.g., salt in place of cocaine). The therapist, in this way, would be trying to simulate an outside experience that the client may encounter when not in the safe zone of therapy. If the client experiences a craving, in view of the paraphernalia and simulated drug, the therapist could then help the client think through alternatives. Rather than reacting to the craving and using the drug, the client could call a sponsor, go for a walk, head to the gym, see a movie, or simply think it through (in a similar way to a skilled meditator or yogi). Dr. Beck’s sample technique further illuminates CBT’s commitment to empowering clients, building skills, and creating healthy outcomes.

Although Cognitive Behavioral Therapy is limited in time, while this therapy may commence during a rehab stay, it can continue afterwards. Typically, rehab programs offer both individual and group therapy. CBT is amenable to both types. Many rehabs offer Cognitive Behavioral Therapy, and this approach can be combined with other therapy types. It is also possible for a person to find a CBT therapist after completion of the rehab program (i.e., as part of an aftercare program). As reflected in this discussion, CBT can be used to understand and improve a person’s thinking, behaviors, and emotions around different issues. A person, therefore, may find that after stopping CBT for one issue, it can be helpful to resume sessions for another issue. The techniques are largely the same across different issues.

For therapists who are interested in reading more about CBT, Dr. Beck recommends Cognitive Group Therapy for Addiction Counselors by Amy Wenzel. For non-professionals, there are a host of e-books, books, and online articles available. One best-selling CBT book, written for a lay audience, is Cognitive Behavioral Therapy: 7 Ways to Freedom from Anxiety, Depression, and Intrusive Thoughts (Training, Techniques, Course, Self-Help) by Lawrence Wallace. Of course, the best way to learn about Cognitive Behavioral Therapy is to engage in the therapy, especially during an inpatient or outpatient rehab program.